Inspection on 01/09/05 for Haven House

This inspection was carried out on 1st September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Haven House 13/04/10

Haven House 15/12/09

Haven House 02/01/09

Haven House 05/11/08

Haven House 03/07/08

Haven House 08/01/08

Haven House 30/05/07

Haven House 11/05/06

Haven House 04/05/05

Haven House 23/11/04

Haven House 29/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Haven House Residential Ltd Warwick Road Kineton Warwick CV35 0HN Lead Inspector Jean Thomas & Christy Wannop Unannounced 1 September 2005 08:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Haven House Residential Ltd Address Warwick Road Kineton Warwick Warwickshire CV35 0HN 01926 641714 01926 641714 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Haven House Residential Limited Care Home 20 Category(ies) of Old Age - (20) registration, with number of places Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 4 May 2005 Brief Description of the Service: Haven House is a conversion of three period houses in the large village of Kineton. There are twenty single bedrooms, nineteen of which have en-suite facilities. There is a shaft lift as well as two staircases, one at each end of the home. There are two sitting rooms and a dining room, and there is level access to the attractive walled garden at the rear, which gives access to the car park. Haven House is within a few minutes level walk of the village centre of Kineton, which has three churches, hairdressers, a variety of shops, restaurants, pubs, banks and a post office. Two doctors’ surgeries, a chiropodist, an optician and a dentist are all nearby. There is a limited ‘bus service to Stratford-UponAvon, Banbury, Leamington Spa and surrounding villages. Nursing care is not provided. Residents in need of attention from a nurse have access to the community nursing service, as they would in their own homes. Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a period of seven hours. The owner and deputy manager were available. Three residents’ records were viewed. Five members of staff were interviewed. Eight residents talked to the inspectors about the care provided by the home. What the service does well: What has improved since the last inspection? What they could do better: Greater effort needs to be made to ensure risk assessments with residents are undertaken and include the prevention of falls, manual handling, nutritional Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 6 screening and self-administration of medication. Risk assessments undertaken in respect of the first floor windows and the adequacy of window restrictors fall short of what is required. The absence of effective risk management strategies place residents at risk of harm or injury. In order to provide a clean and safe home environment, action must be taken by the owner to raise the standards of cleanliness in the home. Care plans are not sufficiently detailed therefore further information and guidance is needed to ensure that the staff have direction in the care to be given. Staff induction training must be provided and foundation training implemented to ensure that the work force is suitably trained for their individual roles and responsibilities. The home has an infection control policy, which is not being followed by the staff. Staff involved in food preparation must participate in basic food hygiene training. The absence of appropriate staff training and poor staff practices place people in the home at risk of cross infection and/or food contamination. In order to reduce risk, staff training, a review of the infection control procedure and monitoring of staff practices is necessary to ensure that staff adopt effective infection control measures. Sufficient resources (propane gas) necessary to provide a daily cooked meal must be made available and any cooking equipment used (camping stove) is first subjected to the relevant safety checks. Failure to provide appropriate and safe equipment places people in the home at risk of harm or injury. In order to ensure people using the service are aware that complaints can be made directly to the Commission for Social Care Inspection (CSCI) at any stage of the complaints process, this information should be included in the complaints procedure and in the Service Users Guide. The absence of a policy and procedure covering staff management, staff involvement in service users’ finances and in making or benefiting from residents’ wills place residents at risk of financial abuse. A structured staff induction programme must be introduced to ensure that new staff are formally introduced to the working practices of the home, failure to implement a staff induction programme could reduce the consistency of care and poor practices could develop. Effective and structured staff induction training also ensures that the work force is suitably trained for their individual roles. A fire risk assessment must be undertaken to make sure action is taken to minimise any identified risk, and action taken to ensure that items of furniture or equipment are not stored in front of fire extinguishers. Obstruction to fire fighting equipment also place people in the home at risk. A review of the Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 7 home’s fire procedures/drills is also required to ensure that the fire brigade is called as soon as the fire alarm has been activated, any delay in the process place people in the home at risk. There are a number of areas of concern that remain outstanding since the last inspection. Action must be taken to bring about improvements in the following areas: • • • • A commitment to providing the means for staff to complete a National Vocational Qualification (NVQ) in care to ensure staff are appropriately qualified. The implementation of rigorous staff selection and recruitment policies and procedures necessary for ensuring only suitable people are employed. An action plan to raise the standard of the décor, maintenance and replacement of furnishings and fixtures at the home, in order to improve the environment. Fresh, nutritious and wholesome food must be readily available to residents in order to ensure nutritional needs are being met. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 4 Residents are generally satisfied with the care and support provided by the staff. Although a basic care needs assessment is undertaken prior to moving into the home, individuals cannot be sure their needs will be met. EVIDENCE: In the absence of a care management assessment undertaken by social services, the acting manager assesses the needs of residents prior to admission. The forms are basic and cover the main areas associated with health and well-being. Staff are not always aware of information held in the initial care needs assessment, therefore needs are unmet. One person admitted to the home had been unable to have their care needs met, and after a period of five weeks was transferred to more suitable accommodation. Residents generally said they were settled at the home, there was a good level of satisfaction. Most spoken to said they had not had a choice or opportunity to visit the home prior to admission. Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 and 10 The residents’ health, personal and social care needs are not clearly set out in the individual plans consequently not all care needs are met. The staff ensure that the privacy and dignity of the residents is respected, consequently the residents maintain individuality. EVIDENCE: Care plans are developed from the initial assessment; the plans of care need to contain more information to ensure that all needs are met properly. Three care plans were viewed, one stated that the resident needed help to get out of bed but failed to identify what action was to be taken by staff to ensure consistency and safety. One care plan indicated that a resident was ‘sometimes’ incontinent but failed to identify how continence was to be managed, therefore needs unmet. Information held in another care plan showed that prior to admission a resident sustained a fall at home and as a result was hospitalised. The care plan stated that ‘she was able to mobilise prior to the fall so encourage her to stand and take a few steps’. The absence of a falls risk assessment placed the resident at risk of harm or injury. Some care plans held evidence of family members being consulted at care plan Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 11 review meetings. The home has now devised a standard letter inviting family members to participate and attend care planning meetings and reviews. Three staff spoken to were not fully aware of all the information held in care plans. Two residents spoken to said they had been involved in planning their care whilst one resident said they were not aware of any care plan. Residents were very relaxed in this home. Apart from one resident who would have preferred to remain in her own community, all those residents spoken to expressed how happy they were to be living at Haven House. Residents also stated that they are treated with kindness at all times. Staff were observed to be respectful to residents during their day-to-day practice. Residents have access to district nurses, GPs, and other health care professionals as they would if living in their own home in the community. One resident spoken to was being cared for in a hospital bed with a pressurerelieving mattress. When needing assistance to get out of bed the resident said that she sometimes used a turntable. A risk assessment had not been undertaken therefore the resident was at risk. Nutritional screening does not take place at the time of admission to the home. One resident with dietary and health care needs was not weighed for four months after admission to the home. Where there were concerns that dietary needs were not being appropriately met, the absence of effective monitoring of weight and dietary intake place residents health at risk. Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 14 and 15 Visiting is flexible and takes into account the expressed needs of residents. The home supplies three main meals each day and residents are given a choice at each mealtime. The staff consult with residents about food at the Residents’ Committee meetings. A variety of provisions are not held, therefore residents preferring an alternative to what is on offer, have only very limited options available to them. EVIDENCE: Residents spoken to said that they were free to make their own decisions about their daily lives and that staff respect these decisions. The home has a flexible visiting policy that takes into account the expressed needs and wishes of residents. The kitchen cupboards, fridge and freezer held a small amount of value brand provisions purchased from a supermarket. In order to ensure residents’ nutritional needs are being met, a range of food should always be readily available. The nutritional value of the diet provided to the residents should be assessed. Some care staff had undertaken training in nutrition for elderly people but this knowledge was not apparently applied for the benefit of residents. These issues were raised and discussed with the owner who said that he now plans to purchase brand name provisions from a recognised provisions Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 13 provider, and will take steps to increase the amount and range of provisions held for the benefit of residents. An assessment of nutritional needs and details of residents’ likes and dislikes were not documented in care plans examined therefore nutritional needs may not be met appropriately. Observation of practices found that residents were offered the choice of two main meals at lunchtime. The lunch was served in a relaxed manner; therefore ensuring residents were not hurried. One resident admitted to the home the day before and assessed as requiring a soft diet was served a normal diet, therefore specialist dietary needs were not met. To assist with eating and to promote dignity and independence one resident had been provided with adapted utensils. The daily menu was not accurate as the food provided on the day of the inspection differed to that on the menu. In order to avoid any unnecessary confusion or disappointment, menus should accurately reflect the food available. Burnt boiled potatoes served to residents on the day of the inspection were attributed to the use of a camping stove loaned to the home by the cook, after the propane gas needed to operate the cooker had run out the day before. The owner must ensure that suitable arrangements are made for the provision of a cooked meal and that any equipment used is first subjected to the relevant safety checks. Failure to provide appropriate and safe equipment places people in the home at risk of harm or injury. Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 Clear messages are given to staff and residents about how to make complaints and the home’s attitude of not tolerating abuse. EVIDENCE: Complaints and abuse information was laminated and displayed in residents bedrooms and throughout communal areas. The home has a complaints procedure but it has never been used. Historical letters of thanks from relatives are displayed, and then filed. The complaints procedure requires revising to include the fact that complaints can be referred to the CSCI at any stage of the process. The systems for protecting vulnerable adults from abuse have never been used. In order to meet previous requirements the procedure for reporting allegations of abuse has been revised and now includes the contact details for the Police, Social Services and the Commission. Staff spoken to were aware of the ‘Whistle Blowing’ procedure and gave examples of what actions may constitute abuse. All spoken to said they would report any concerns to the owner. The absence of a policy and procedure covering staff management, staff involvement in service users’ finances and in making or benefiting from residents’ wills place residents at risk of financial abuse. . Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The environment is dirty and not well maintained and so there is a risk of infection for service users and staff. The home is generally tidy. Some repairs are needed to increase the comfort and safety of the residents and improve the appearance of the home. EVIDENCE: Poor practices resulting in toilets not being flushed, wet used face flannels and towels routinely left in communal bathrooms, the use of communal bars of soap, paper hand towels not available in staff toilets, protective gloves and aprons not readily available in the laundry room and commode pans piled in the sluice which is also sited in the laundry room, place the health of people in the home at risk. Communal areas and residents’ private rooms were dirty and some areas of the home were subjected to offensive odours. Thus also creating an unpleasant and unsafe environment for residents to live in. Access to the laundry is situated outside of the main home. This area does not have suitable flooring and the walls cannot be washed. The laundry area was Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 16 not kept in a clean and hygienic state and protective clothing used for the prevention of infection was not readily available. All these factors contribute to the risk of infection. Comments made by residents directly to inspectors, ‘the laundry is of a very good standard’, ‘you can put it out today and it’ll be back tomorrow’, ‘I have no complaints, service very good’. Clothes worn by the residents and those seen in wardrobes were clean, although not all had been ironed. The furniture in the main lounge and dining room is comfortable and in good repair. There are a variety of single chairs. Residents spoken to said they were happy with the lounge and felt comfortable. Residents were encouraged to personalise their private rooms, a number of which were shown to inspectors by the residents. One resident said she was very comfortable and chose to spend most of the time in her room. The home employs one domestic assistant, who is also used to provide cover during the absence of other staff, including care staff, therefore sufficient time is not allocated for cleaning tasks to be completed to an acceptable standard, resulting in a dirty and poorly maintained environment. Some areas of the home smelled of urine. Toilets and bathrooms had not been cleaned and in some areas of the home paint was flaking and wallpaper hanging off the walls. The owner described a programme of refurbishment and it was apparent that some renovations had been undertaken but not completed. Now outdated risk assessments required last year to assess adequacy of the safety of first floor windows did not result in reduction of risk. Five upstairs bedroom windows have safety restrictors. The continued failure to undertake appropriate risk assessments place residents at risk of harm or injury. There is an unmet requirement from the last inspection to supply a written programme of refurbishment to include timescales for replacement of upstairs carpet, fitting of appropriate locks to bedroom doors and bathrooms, deep cleaning of home and specifically bathrooms and laundry, boxing in exposed pipes in bedrooms, repairing water damage, damp damage caused to wallpaper in rooms and corridors, tiling in bathrooms, improving staff toilet. The homes failure to appropriately address these issues also place residents at risk. Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30 The home provides sufficient numbers of staff with an acceptable skills mix to meet the needs of service users. Staffing levels for direct care are satisfactory. The training programme for NVQ and updates for essential training in Food Hygiene is not sufficiently well established or effective. Staff recruitment and selection procedures are becoming safer but are not yet satisfactory. EVIDENCE: Rotas seen for a two week period up to 9/9/05 showed that the staff group was usually four carers each morning, three each afternoon and evening and two staff on night duty. One domestic staff provides relief carer cover, and is qualified to do so, but this means that cleaning duties will not be done. Staffing records for four staff showed that they had carried out a satisfactory range of training. There was however no evidence of a staff induction programme or of foundation training taking place, indicating that staff are not formally introduced to the working practices of the home. The absence of formal induction or completion of a probationary period could reduce the consistency of care and poor practices could develop. Two staff were reported to be nearing completion of a NVQ level 2 in Care. Only one care worker has yet achieved this qualification. Greater effort is required by the provider to ensure residents have their needs met by staff that have the appropriate qualifications for their role. Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 18 The Owner has occasionally arranged for a seventeen year old to supplement low staffing levels. There were no recruitment records or risk assessment undertaken for this young person, who is a relative of a staff member. The home has a recruitment matrix but this was not used on any staff file viewed. The owner should ensure that references are always taken up from the applicants’ most recent employer and that references are always addressed to the Manager rather than a “testimonial” format. Failure to adopt rigorous staff selection and recruitment procedures, necessary to determine fitness, place the safety of residents at risk. Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 and 38 Although the home promotes a range of health and safety policies and procedures there are a number of shortfalls that place residents at risk. There is inadequate leadership, guidance and direction to staff, so there is inconsistent care and safety of residents may be at risk. EVIDENCE: Although the deputy manager is working hard to make improvements the absence of the appointment of a suitable manager has a negative impact on the service, as there is a lack of clarity and leadership. A record of accidents and incidents is held in accordance with the requirements of Health and Safety legislation and by the Care Homes Regulations 2001. A mechanical hoist and small piece of furniture on the first floor were blocking access to the fire extinguisher obstruction of fire fighting equipment place people in the home at risk of harm or injury. As this issue was addressed by the deputy manager at the time of the inspection an immediate requirement Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 20 notice was not issued. The absence of a fire risk assessment place people in the home at risk The home has an infection control policy and a health and safety policy but practices in the home did not comply with the organisations policy, therefore practices were unsafe. A review of the infection control policy and practices at the home is necessary to ensure the safety of residents, and must also include the promotion and maintenance of a clean and hygienic environment. The fire alarm activated during the inspection. Staff responded by reporting to the designated fire assembly point. Staff failed to inform the fire brigade immediately preferring instead to investigate the cause of the alarm being activated. In order to ensure the safety of people in the care home, the fire brigade must be called when the fire alarm has been activated. In order to minimise the risk of fire, a fire risk assessment must also be undertaken and a copy submitted the Commission. The home has a number of COSHH data sheets available to staff. The information held did not include details of the chemicals used by staff in the dishwasher. Data sheets must be updated and include all products that may place staff and residents at risk of harm. A number of staff held a first aid certificate and a first aid box was held in the kitchen. An accident book is held and records were found to be up to date. The kitchen has a daily cleaning programme and records are held of fridge, freezer and high risk cooked food temperatures. The cook has not undertaken training in basic food hygiene or any other food related health and safety topic. The cook was not aware of any risk assessments to cover safe working practice in the kitchen. The date of the most recent visit by the EHO is recorded as 13.12.04. Records were held of service checks on equipment and a new hot water system recently installed. Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score N/A N/A 2 2 N/A N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 N/A 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 N/A 13 N/A 14 3 15 2 COMPLAINTS AND PROTECTION 1 N/A N/A N/A N/A N/A N/A 1 STAFFING Standard No Score 27 1 28 N/A 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 2 N/A 2 1 N/A N/A N/A N/A N/A N/A 2 Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 22 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 3 Regulation 14 Requirement Assessment of needs must be completed in sufficient detail to ensure that staff can meet the needs of residents. Assessments must be completed prior to a residents admission to the home. (Previous timescale of 01.07.05 remains outstanding). Care plans must be completed in sufficient detail to ensure staff can meet the needs of residents. Care plans must be person centred and include all elements of the standards. Care plans must hold a recent photograph of the resident. (Previous timescale of 01.08.05 remains outstanding). Risk assessments must be in place for any individuals requiring assistance with moving and handling and/or any other activity that may pose a risk. (Previous timescale of 01.07.05 remains outstanding). Details of any plan relating to the residents nutritional needs must be held. The Registered Provider must ensure that residents have Timescale for action 31.09.05 2. 7 15 31.10.05 3. 7 13,14,15 30.09.05 4. 5. 8 15 17 (1) (a) Schedule 3 16 14.10.05 Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 23 6. 16 22(a) 7. 18 20,17 (2) Schedule 4 8. 19 16 & 23 9. 19 13 access to fresh fruit at all times. Evidence must be provided to the Commission of the nutritional value of the current diet. (Previous timescale of 01.07.05 remains outstanding). The complaints procedure must be revised to include the name, address and telephone number of the Commission where complaints can be referred to at any stage of the process. The Registered Provider must devise a policy and procedure covering staff management and involvement in service users’ finances and in making or benefiting from residents’ wills. The Registered provider must devise a planned programme of redecoration, replacement, regular maintenance and refurbishment. (A copy of which must be sent to the Commission). This plan must include: the replacement of the upstairs corridor carpet, regular cleaning of windows, fitting of appropriate security locks to the doors of residents private rooms, the provision of lockable storage space in residents private rooms, the deep cleaning of bathing equipment, the repair of the cupboard door in bathroom. (Some elements of this requirement remain outstanding since 30.06.04 & 31.01.05). The Registered Provider must risk assess all of the first floor windows and the adequacy of any window restrictors. The risk assessments must also include details of any risk management strategy. (Previous timescale of 31.01.05 & 01.07.05 remain outstanding). 31.10.05 14.11.05 31.10.05 14.10.05 Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 24 10. 11. 26 29 12. 30 13. 30 14. 30 15. 16. 31 38 The Registered Provider is required to ensure that all parts of the care home are kept clean. 19 The Registered Provider must ensure that rigorous staff selection and recruitment policies and procedures are in place to determin staff fitness, and must also include a risk assessment for any person employed who is under the age of 18years. (Some elements of this requirement did meet the previous timescale which was immediate. Other elements with a timescale of 31.01.05 remain outstanding). 18 The Registered provider must promote and give commitment to providing the means for staff to complete a National Vocational Qualification in social care. (Previous timescale of 28.02.05 remains outstanding, A revised time scale of 01.11.05 was issued to the Provider following the last inspection). 18 Staff preparing and handling food must be trained in basic food hygiene practices. (Previous time scale of 30.06.04, 31.01.05 & 01.08.05 remain outstanding). 12(1)(a)( The registered provider must b), ensure that there is a suitable 18(1)(a)(c staff induction and foundation ) training programme for care staff to commence once they have been confirmed in post. 8 (1) (3) The Registered Provider shall appoint a suitable individual to manage the care home. 13 (3) The Registered Provider is required to revise the infection control policies and procedures and to ensure staff promote safe practices. E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc 23 (2) (d) 31.11.05 31.10.05 01.11.05 30.09.05 31.10.05 31.11.05 31.10.05 Haven House Residential Ltd Version 1.40 Page 25 17. 38 23 (4) (e) 18. 38 13 (4) 19. 38 13 (4) The Registered Provider is required to ensure that by means of fire drills and practices at suitable intervals staff are aware of the fire procedure to be followed. A fire risk assessment must also be undertaken and a copy forwarded to the Commission. The Registered provider is required to ensure that COSHHE Data sheets are available for all chemicals held or used at the home. The Registered Manager must ensure that any second hand portable appliances brought into the for use by staff are not used before appropriate safety checks are carried out. 14.10.05 14.11.05 14.11.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 15 Good Practice Recommendations The daily menu should reflect the choices available. Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 26 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Haven House Residential Ltd E53 S4321 Haven House Residential Ltd V246949 010905 Stage 4.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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